This article includes the questions asked by Bp Premier users during a recording of the BeInTheKnow: Chronic Disease Management Changes July 2025 presented by Best Practice Software and Cubiko on the 10 – 12 June 2025.
NOTE This article will be updated as additional information becomes available. Visit the MBS Online website for more information about the upcoming changes to the MBS Chronic Disease Management Framework.
In this article:
What is changing on 1 July 2025?
From 1 July 2025, a new framework for Chronic Disease Management will be introduced by the Australian Government, based on recommendations from the MBS Review Taskforce, and is designed to streamline care planning, reduce administrative burden, and strengthen continuity of care.
The current GP Management Plans (GPMPs) and Team Care Arrangements (TCAs) will be replaced by a single care plan: the GP Chronic Condition Management Plan (GPCCMP).
The changes are part of the government’s Strengthening Medicare initiative, focused on improving patient outcomes and reducing complexity.
The Chronic Disease Management (CDM) framework aims to:
- Make care planning easier for practices and patients
- Encourage regular, structured reviews
- Reduce paperwork and streamline referral and claiming processes
- Strengthen continuity of care through the MyMedicare patient registration system.
What is the GP Chronic Condition Management Plan (GPCCMP)?
The new framework for Chronic Disease Management introduces the GP Chronic Condition Management Plan (GPCCMP), which will replace the existing GP Management Plan (GPMP), Team Care Arrangement (TCA), and related review items.
This means your team will move from managing two separate planning processes to a single, streamlined approach.
A GPCCMP outlines the patient’s chronic conditions, care goals, treatment actions, referrals (if needed), and a review schedule.
Under the Chronic Condition Management Plan:
- You will no longer need to coordinate with two additional providers as part of a TCA.
- Referrals to allied health providers will be made via a referral letter rather than a structured form.
- New MBS item numbers will apply for plan preparation and review (face-to-face and video). All existing GPMP and TCA items will be retired.
- Patients registered with MyMedicare will be required to access chronic condition management plans and reviews through their registered practice. Patients not registered with MyMedicare can continue to access these services through their usual GP.
Who is eligible for a GPCCMP?
There is no list of eligible conditions. Any patient with a chronic condition likely to be present for six months or more—or who has a terminal illness—is eligible.
It is up to the GP or PMP’s clinical judgement to determine whether an individual patient with a chronic condition would benefit from a GPCCMP.
GPCCMPs are not available to patients in residential aged care facilities. Allied health services are available to these patients through a multidisciplinary care plan.
Which MBS-supported services are available to patients with a valid GPCCMP?
Patients can access the following MBS-supported services where they are consistent with their GPCCMP:
- Up to 5 individual allied health services per calendar year (10 services for patients of Aboriginal or Torres Strait Islander descent).
- Up to 5 services provided on behalf of a medical practitioner by a practice nurse or Aboriginal and Torres Strait Islander Health Practitioner.
- For patients with type 2 diabetes, an assessment of their suitability for group dietetics, diabetes education, or exercise physiology services is conducted, and if suitable, up to 8 group services for diabetes management are provided per calendar year.
Visit the MBS Online website for more information on the MBS Items for GP Chronic Condition Management Plans.
What are the new MBS item numbers for GPCCMPs?
From 1 July 2025, the following MBS item numbers used for GP Management Plans (GPMPs), Team Care Arrangements (TCAs), and reviews will be ceased:
- GP management plans – 229, 721, 92024, 92055
- Team care arrangements – 230, 723, 92025, 92056
- Reviews – 233, 732, 92028, 92059.
The ceased items will be replaced by a new set of item numbers that support the introduction of the GP Chronic Condition Management Plan (GPCCMP).
The new items apply to both face-to-face and telehealth video services and are designed to reflect updated clinical and administrative requirements.
|
|
General Practitioner item numbers |
Prescribed medical practitioner item numbers (non-VR) |
|---|---|---|
New items (from 1 July 2025) |
||
|
Develop a GP chronic condition management plan (GPCCMP) |
Face to Face – 965 |
Face to Face – 392 |
|
Telehealth (Video)– 92029 |
Telehealth (Video) – 92060 |
|
|
Review a GP chronic condition management plan |
Face to Face – 967 |
Face to Face – 393 |
|
Telehealth (Video) - 92030 |
Telehealth (Video) - 92061 |
|
Visit the MBS Online website for more information on the MBS Items for GP Chronic Condition Management Plans.
How often can a GPCCMP be prepared or reviewed?
Plans can be prepared once every 12 months or earlier in exceptional cases.
Reviews can be done every 3 months if clinically required.
Visit the MBS Online website for more information on the MBS Items for GP Chronic Condition Management Plans.
How does MyMedicare registration affect GPCCMPs?
If a patient is registered with MyMedicare, they must access GPCCMP services from their registered practice.
Patients who are not registered with MyMedicare can continue receiving these services from their usual GP.
Can we bill a standard consult on the same day as a GPCCMP?
No. Consistent with current arrangements, items for the preparation or review of a GPCCMP cannot be co-claimed on the same day as general attendance items (e.g., 3, 23, 36).
Visit the MBS Online website for more information on the MBS Items for GP Chronic Condition Management Plans.
Do we still need to upload the plan to My Health Record?
Yes, if the patient consents. Uploading care plans helps ensure care continuity, especially when patients engage with multiple health providers.
Visit the MBS Online website for more information on the MBS Items for GP Chronic Condition Management Plans.
Do these changes affect other care plans like mental health or DVA?
No. These requirements do not apply to other MBS-supported allied health services such as Mental Health Treatment Plans, Eating Disorder Plans, Palliative Care, and DVA services. These plans remain under their existing frameworks and item numbers.
Visit the MBS Online website for more information on the Referral Arrangements for Allied Health Services.
What changes are there to allied health referrals?
From 1 July 2025, referrals to Allied Health Services can be issued using a standard referral letter and no longer require a structured Medicare form.
To provide patients with greater choice and flexibility. Referrals to allied health services do not need to:
- Specify the name of the allied health provider to provide the services.
- Specify the number of services to be provided.
- Referring medical practitioners can still specify the number of services to be provided under the referral if they choose to do so.
Patients can access care from any eligible allied health provider, regardless of their location or availability.
Key changes from 1 July 2025:
- Referral letters remain valid for up to 18 months, unless otherwise stated.
- Allied health providers must continue to send written reports back to the referring GP following certain services.
- Referrals may be signed and sent electronically.
- Referrals created before 1 July 2025 under GPMP/TCA arrangements remain valid until the allocated services are completed.
Visit the MBS Online website for more information on the Referral Arrangements for Allied Health Services.
What must be included in a referral letter to allied health providers?
To be valid, referral letters must meet the following the minimum requirements:
- includes the referring practitioners name and provider number or practice address
- include the date of referral
- the validity of the referral (if relevant)
- includes the reason for referral and relevant clinical details
- be in writing
- be signed by the referring practitioner (which may be by electronic signature)
Visit the MBS Online website for more information on the Referral Arrangements for Allied Health Services.
Do allied health providers need to confirm the referral?
No. However, they must still report back to the GP after the first and last service. These feedback reports are a mandatory requirement for Medicare compliance.
Visit the MBS Online website for more information on the Referral Arrangements for Allied Health Services.
What happens to patients with existing GPMPs and TCAs?
For patients that have a GPMP and/or TCA in place prior to 1 July 2025, there is no immediate action required.
- Patients can continue to access allied health and other services under their existing plans until 30 June 2027.
- Referrals written prior to 1 July 2025 will continue to be valid until all services under that referral have been provided.
Patients that require a review of their GPMP and/or TCA after 1 July 2025 can be transitioned to the new GPCCMP at that time.
From 1 July 2027 patients will require a GPCCMP to continue to access allied health and other services.
Visit the MBS Online website for more information on the Transition Arrangements for Existing Patients.
Can patients still use item 10997 under existing plans?
Yes, patients can continue to access services provided through MBS item 10997 (and its telehealth equivalents 93201 and 93203) under existing GPMPs and TCAs until 30 June 2027.
Visit the MBS Online website for more information on the Transition Arrangements for Existing Patients.
What should we do as a practice to prepare?
With the introduction of the GP Chronic Condition Management Plan (GPCCMP) on 1 July 2025, practices are encouraged to begin preparing in advance.
- Register for your practice for MyMedicare
- Educate and enrol patients for MyMedicare
- Educate staff
- Engage with Primary Health Networks (PHNs)
- Finalise GPMP and TCA billings prior to 1 July 2025
- Check for any care plan appointments that have not yet been billed and complete the billing process.
- Review your held invoices and submit any that include GPMP or TCA items.
- Check your debtors list for items incorrectly billed to patients and reissue these claims to Medicare where appropriate.
- Resolve any online claiming rejections related to GPMP or TCA services and resubmit them for payment before the old item numbers are removed.
- Review and update care plan templates
- Review local address book for Allied Health Contacts
Ensure your practice is registered with MyMedicare to facilitate patient enrolment and compliance with the new requirements.
Inform patients, especially those with chronic conditions, about the benefits of MyMedicare registration and assist them in the enrolment process.
Provide training for GPs, practice nurses, and other relevant staff on the new chronic condition management plan requirements and referral processes.
To support practices in understanding the upcoming changes to the Chronic Disease Management framework, Best Practice Software has developed an eLearning course:
Seek support and resources from your local PHN to assist with the transition to the new system and to participate in any available training or informational sessions.
To locate your local PHN, visit the website of the Department of Health, Disability and Ageing and use the Primary Health Network (PHN) locator tool.
All unbilled GPMP and TCA items must be submitted before 1 July 2025. After this date, these item numbers will no longer be claimable through Medicare. It’s recommended that you:
Custom GPMP and TCA templates will not be automatically updated. If your practice uses custom Word Processor templates for chronic disease management, you will need to manually update them to reflect the new plan structure. This includes removing references to separate team care arrangements and ensuring your templates reflect the new GPCCMP model.
See Create and edit word processor templates for more information.
This is a good opportunity to review and update your contact list for local allied health providers. With the move to referral letters (rather than structured TCA forms), ensuring you have accurate, up-to-date details for relevant providers will help maintain referral pathways.
Check contact names, phone numbers, email addresses, and practice locations in your Bp Premier address book and make any necessary updates.
Where can I find more information?
MBS Online resources
For more information, all MBS Fact Sheets are available below:
- Chronic Disease Management Framework Overview Fact Sheet
- Transition Arrangements for Existing Patients
- Referral Arrangements for Allied Health Services
- MBS Items for GP Chronic Condition Management Plans
- What Do the Changes Mean for Practice Nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers?
- What Do the Changes Mean for Allied Health Providers?
Cubiko
- Chronic Condition Management Hub — access guides, tools, and practical tips to help your practice prepare for the changes in Chronic Condition Management.
RACGP
MyMedicare
For more information on MyMedicare see:
- MyMedicare — Australian Government Department of Health and Aged Care
- Information for MyMedicare general practices and healthcare providers — Australian Government Department of Health and Aged Care
- Information for MyMedicare patients — Australian Government Department of Health and Aged Care
For more information on how to manage MyMedicare in your practice:
- Services Australia — navigating PRODA / HPOS for MyMedicare and General Practice in Aged Care Incentive (GPACI) with eLearning Modules; Infographics and Simulations for ease of understanding.
Information correct at time of publishing (13 June 2025).
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